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Medical Policy Manual Page Image Page Content The Medical Policy Manual is updated on a routine basis. Please click on the link below for a current summary of updates. Download Summary of Updates All services provided must be medically necessary as determined by the member's practitioner or provider in consultation with PHP. Behavioral Health Clinical Medical Necessity Criteria (Medicaid Centennial Care) Behavioral Health Medical Necessity Criteria (Medicare/Commercial) Magellan NIA Medical Necessity CriteriaA Allergen Immunotherapy, MPM 44.0 Allergy Testing, MPM 45.0 Ambulance Services, MPM 1.1 Autism Spectrum Disorders: Diagnosis and Treatment, MPM 1.4 Autologous Chondrocyte Implantation (Carticel), MPM 3.2 B Balloon Dilation for ENT Procedures, MPM 2.12 Bariatric Surgery (Weight Loss Surgery) for Medicare, MPM 2.82 Bariatric Surgery (Weight Loss Surgery) for Non-Medicare, MPM 2.81 Bariatric Surgery for Pediatric Population, MPM 40.0 Blepharoplasty/Ptosis Surgery, MPM 2.7 Bone Anchored Hearing Aid (BAHA), MPM 2.9 Breast Surgical Procedures, MPM 27.0 Breast Ultrasound, MPM 24.1 Bronchial Thermoplasty For Treatment of Asthma, See MPM 36.0 C Cancer Clinical Trials, Routine Patient Care Costs, Coverage for Commercial and Medicaid, MPM 3.7 Capsule Endoscopy, MPM 24.0 Cervical and Lumbar Spinal Procedures, MPM 25.1 Chimeric Antigen Receptor (CAR) T-cell Therapy, MPM 32.0 Cholecystectomy, MPM 3.9 Clinical Trial Coverage for Members Enrolled in a Medicare Plan, MPM 3.8 Continuous Glucose Monitoring Systems (See DME: Diabetic Equipment, MPM 4.4) Corneal Cross-Linking for Keratoconus and Ectasia, MPM 28.0 COVID-19 Testing, MPM 43.0 Cranial Orthotic Devices, (See DME: Orthotics and Prosthetics, MPM 4.6) D Diapers for Centennial Care Members, MPM 4.8 Durable Medical Equipment: Alternating Electromagnetic Field Therapy for Glioblastoma, MPM 34.0 Durable Medical Equipment: Bath Aids for Medicaid, MPM 48.0 Durable Medical Equipment: For Individuals with Diabetes (Formerly Durable Medical Equipment: Diabetic Equipment), MPM 4.4 Durable Medical Equipment: Miscellaneous, MPM 4.5 Durable Medical Equipment: Orthotics and Prosthetics, MPM 4.6 Durable Medical Equipment: Positive Airway Pressure (PAP) and Oral Appliances for Treatment of Obstructive Sleep Apnea, MPM 49.1 Durable Medical Equipment: Pneumatic Compression Devices, MPM 5.0 Durable Medical Equipment: Rehabilitation and Mobility Devices, MPM 4.2 Durable Medical Equipment: Respiratory Devices, MPM 4.3 E Epidural Corticosteroid Injections, MPM 5.9 Exhaled Nitric Oxide Testing for the Diagnosis/Management of Asthma, See MPM 36.0 Extracorporeal Photopheresis, MPM 5.7 Extracorporeal Shock Wave Therapy for Musculoskeletal Disorders, MPM 5.6 F Facet Joint Interventions for Pain Management (Formerly Paravertebral Facet Joint Denervation), MPM 16.6 Foot Splints for Club Foot (See DME: Orthotics and Prosthetics, MPM 4.6) G Gastric Electric Stimulation for the Treatment of Chronic Gastroparesis, MPM 7.2 Gender Affirming Treatment and Surgery (Adult, 18 years of age and older), MPM 7.3 Gender Affirming Treatment for Children and Adolescent (17 y/o and under), MPM 7.31 Genetic and Genomic Testing (Disease Specific), MPM 7.1 Genetic Testing: Cologuard for Colorectal Cancer Screening, MPM 7.4 Genetic Testing for Breast Cancer Recurrence and Predictive, MPM 33.0 Genetic Testing for Cutaneous Melanoma for Medicare, MPM 7.7 Genetic Testing: Hypercoagulability/Thrombophilia, MPM 7.11 Genetic Testing, InvisionFirst Liquid Biopsy for Lung Cancer, MPM 39.1 (Formerly MPM 37.0) Genetic Testing for Lynch Syndrome, MPM 7.5 Genetic Testing: Next Generation Sequencing, MPM 29.0 Genetic Testing for Non-Invasive Prenatal Testing (NIPT) (Formerly Non-Invasive Prenatal Testing (NIPT)), MPM 20.15 Genetic Testing for Pancreatic Cyst (PathfinderTG®/PancraGen™), MPM 7.6 Genetic Testing, Plasma-Based Genomic Profiling in Solid Tumors, MPM 39.0 Genetic Testing for Prostate Cancer, MPM 7.8 Genetic Testing for Uveal Melanoma, MPM 7.9 Genetic Testing for Whole Exome Sequencing, MPM 7.12 H Home Health Care, for Medicare and Commercial, MPM 47.0 Hyperbaric or Topical Oxygen Therapy (HBOT), MPM 8.6 Hypoglossal Nerve Stimulator, MPM 46.0 Hysterectomy, MPM 8.9 I Implantable Cardioverter Defibrillators (ICD), MPM 9.5 Interspinous Process Decompression (IPD) System (Formerly X-STOP® Interspinous Process Decompression (IPD) System), See MPM 36.0 Intervertebral Differential Dynamics Therapy (IDD Therapy), See MPM 36.0 Investigative & New Technology Assessment List (Non-Covered Services), MPM 36.0 L LINX Reflux Management System for the Treatment of GERD, See MPM 36.0 M Medicaid Home Health Services, MPM 13.6 Meniscal Allograft Transplantation, MPM 13.3 Minimally Invasive Lumbar Decompression MILD and Percutaneous Image Guided Lumbar Decompression (PILD), MPM 13.5 Mobile Cardiac Outpatient Telemetry™ (MCOT™) and Real-time Continuous Attended Cardiac Monitoring Systems, MPM 13.2 Multi-biomarker (Vectra™ DA) test for Rheumatoid Arthritis, MPM 42.0 N Next Generation Sequencing, MPM 29.0 Non-Invasive Prenatal Testing (NIPT), MPM 20.15 O Obstetric US 3D, 4D, 5D, MPM 15.4 Osteogenic Bone Growth Stimulators, MPM 15.2 Outpatient (in Facility) Observation, MPM 50.0 P Panniculectomy and Abdominoplasty, MPM 16.5 Paravertebral Facet Joint Denervation (See Facet Joint Interventions for Pain Management, MPM 16.6) Percutaneous Coronary Interventions MPM 9.7 Percutaneous Neuromodulation Therapy, See MPM 36.0 Pharmacogenetic Testing for Warfarin Dosing (See Genetic and Genomic Testing, MPM 7.1) Pharmacogenomics Testing: Behavioral Health, for Medicare (Formerly Genesight Assay for Refractory Major Depression for Medicare), MPM 30.0 Photodynamic Therapy for Ocular Conditions, MPM 16.15 Plasma Exchange: Therapeutic Apheresis, MPM 16.11 Platelet-Rich Plasma and Platelet-Derived Growth Factor Products, for the Treatment of Wounds and Other Injuries, MPM 16.16 Positron Emission Tomography (PET), MPM 16.1 Prophylactic, Risk Reduction Surgery, MPM 16.10 Prostate: Surgical Treatment for Benign Prostate Hyperplasia, MPM 12.3 Proton Beam Therapy (See Radiation Oncology: Proton Beam Therapy, MPM 16.14) R Radiation Oncology: Proton Beam Therapy, MPM 16.14 Restorative/Reconstructive/Cosmetic Surgery and Treatment, MPM 18.5 S Sacral Nerve Stimulation for Urinary and Fecal Incontinence, MPM 51.0 Secca® Procedure for Fecal Incontinence, See MPM 36.0 Sleep Studies, Attended (In-Laboratory) Full-Channel Polysomnography, MPM 49.0 Subtalar Arthroereisis Implants for Pediatric Patients, See MPM 36.0 T Thermal Intradiscal Procedures (TIP), (includes IDET and Nucleoplasty) AKI: Intradiscal Electrothermal Therapy (IDET), See MPM 36.0 Tissue-Engineered/Bioengineered Skin Substitutes (Application and Use), MPM 35.0 Tonsillectomy, MPM 20.0 Total Ankle Replacement, MPM 20.10 Total Hip Resurfacing, MPM 20.9 Total Joint Replacement Hip and Knee for Non-Medicare, MPM 20.14 Total Joint Replacement Hip and Knee for Medicare, MPM 20.13 Transcranial Magnetic Stimulation for Treatment Resistant Depression for Commercial, MPM 20.16 Transcranial Magnetic Stimulation for Treatment Resistant Depression for Medicare, MPM 20.11 Transoral Incisionless Fundoplication (TIF) for Treatment of GERD, MPM 20.12 Transplants, Bone Marrow and Peripheral Stem Cell, MPM 20.3 Transplants, Organ, MPM 20.6 U Unicompartmental Knee Replacement, MPM 41.0 V Vagus Nerve Stimulation for Epilepsy and Depression, MPM 22.4 Varicose Vein and Venous Stasis Disease of Lower Extremity Procedures, MPM 22.1 Virtual Colonoscopy, Diagnostic, MPM 22.0 W Water Vapor Thermal Therapy for LUTS/BPH, MPM 52.0 Whole Breast Ultrasound, Semi-Automatic, See MPM 36.0 Additional Content Back To Top Sidebar Content